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Division of Public Health Surveillance and Informatics
Epidemiology Program Office

in collaboration with

John D. Hatmaker
Affiliated Computer Services

Preface

The Summary of Notifiable Diseases, United States, 2002 contains the official statistics, in tabular and graphic form, for
the reported occurrence of nationally notifiable diseases in the United States for 2002. The data are final totals for 2002 reported as of June 30, 2003, unless otherwise noted. These statistics are collected and compiled from reports sent by state health departments to the National Notifiable Diseases Surveillance System (NNDSS), which is operated by CDC in
collaboration with the Council of State and Territorial Epidemiologists (CSTE). The Summary is located on the Internet at
http://www.cdc.gov/mmwr/summary.html. This site also includes publications from past years.

The Highlights section presents noteworthy epidemiologic or prevention information for 2002 for selected diseases
and additional information to aid in the interpretation of surveillance and disease-trend data.

Part 1 contains tables showing incidence data for each of the nationally notifiable diseases during 2002.* The tables provide the number of cases reported to CDC for 2002, as well as the distribution of cases by month, geographic location, and
by patient's age, sex, race, and Hispanic ethnicity. Nationally notifiable diseases that are reportable in <40 states do not appear in these tables. Part 2 contains graphs and maps that depict summary data for many of the notifiable diseases described in
tabular form in Part 1. Part 3 contains tables that list the number of cases of notifiable diseases reported to CDC since 1970. This section also includes a table enumerating deaths associated with specified notifiable diseases reported to the National Center for Health Statistics (NCHS), CDC, during
1996--2000. The Selected Reading section presents general and disease-specific references for notifiable infectious diseases. These references provide additional information on surveillance and epidemiologic issues, diagnostic issues, or disease control activities.

_______________________

* Because no cases of paralytic poliomyelitis and western equine encephalitis were reported in the United States during 2002, these diseases do not appear in the tables in Part 1.

 In 1999, mortality data began to be coded according to the
International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. To bridge the mortality data for the period 1996--1998 (deaths coded using the International Classification of Diseases, Ninth
Revision), and 1999--2000, we use comparability ratios provided by the National Center for Health Statistics.

Background

The infectious diseases designated as notifiable at the
national level during 2002 are listed on page 3. A notifiable disease
is one for which regular, frequent, and timely information regarding individual cases is considered necessary for the
prevention and control of the disease. This section briefly summarizes the history of the reporting of nationally notifiable diseases in the United States.

In 1878, Congress authorized the U.S. Marine Hospital Service (the forerunner of the Public Health Service [PHS])
to collect morbidity reports regarding cholera, smallpox, plague, and yellow fever from U.S. overseas consuls. The intention was
to use this information to institute quarantine measures to prevent the introduction and spread of these diseases into the
United States. In 1879, a specific Congressional appropriation was made for the collection and publication of
reports of these notifiable diseases. Congress expanded the
authority for weekly reporting and publication of these reports in 1893 to include data from states and municipal
authorities. To increase the uniformity of the data, Congress enacted a law in 1902 directing
the Surgeon General to provide forms for the collection and compilation of data and for the publication of reports at the national level. In 1912, state and territorial health authorities --- in conjunction with PHS --- recommended immediate
telegraphic reporting of five infectious diseases and the monthly reporting, by letter, of 10 additional diseases. The first annual summary of The Notifiable Diseases in 1912 included reports of 10 diseases from 19 states, the District of Columbia, and Hawaii. By
1928, all states, the District of Columbia, Hawaii, and Puerto Rico were participating in national reporting of 29 specified
diseases. At their annual meeting in 1950, state and territorial health officers
authorized the Council of State and Territorial Epidemiologists (CSTE) to determine which diseases should be reported to PHS. In 1961, CDC assumed responsibility for the collection and publication of data concerning nationally notifiable diseases.

The list of nationally notifiable diseases is revised periodically. For example, a disease might be added to the list as a
new pathogen emerges, or a disease might be deleted as its incidence declines. Public health officials at state health departments
and CDC continue to collaborate in determining which diseases should be nationally notifiable. CSTE, with input from
CDC, makes recommendations annually for additions and deletions. Although disease reporting is mandated by legislation
or regulation at the state and local levels, state reporting to CDC is voluntary. Thus, the list of diseases considered notifiable
varies slightly by state. All states generally report the internationally quarantinable diseases (i.e., cholera, plague, and yellow fever) in compliance with the World Health Organization's International Health Regulations.

Data Sources

Provisional data concerning the reported occurrence of
notifiable diseases are published weekly in the
MMWR. After each reporting year, staff in state health departments finalize reports of cases for that year with local or county
health departments and reconcile the data with reports previously sent to CDC throughout the year. These data are compiled in final form in the Summary.

Notifiable disease reports are the authoritative and archival counts of cases. They must be approved by the
appropriate epidemiologist from each submitting state or territory before being published in the
Summary. Data published in CDC Surveillance
Summaries or other surveillance reports produced by CDC programs might not agree exactly with data reported
in the annual Summary because of differences in the timing of reports, the source of the data, or surveillance methodology.

Data in the Summary were derived primarily from reports transmitted to the Division of Public Health Surveillance
and Informatics, Epidemiology Program Office, CDC, from health departments in the 50 states, five territories, New York
City, and the District of Columbia. More information regarding notifiable diseases, including case definitions for these conditions, is available on the Internet at
http://www.cdc.gov/epo/dphsi/phs.htm. Policies for reporting notifiable disease cases can vary
by disease or reporting jurisdiction.

Final data for some diseases are derived from the surveillance records of the CDC programs listed below. Requests for
further information regarding these data should be directed to the
appropriate program.

Disease totals for the United States, unless otherwise stated, do not include data for American Samoa, Guam, Puerto Rico, the U.S. Virgin Islands, or the Commonwealth of the Northern Mariana Islands.

Population estimates for the states are from the U.S. Census Bureau, Population Division, Table ST-EST2002-01 -
State Population Estimates: April 1, 2000, available at
http://eire.census.gov/popest/data/states/tables/NST-EST2003-01.php.
Numbers for territories are estimates from the U.S. Bureau of the Census, International Data Base, available at
http://www.census.gov/ipc/www/idbprint.html. The choice of population denominators for incidence rates reported in the
MMWR is based on 1) the availability of census population
data at the time of preparation for publication, and 2) the desire
for consistent use of the same population data to compute incidence rates reported by various CDC programs. Rates in the Summary are presented as incidence rates per 100,000 population, based on data for the U.S. total resident
population. However, population data from states in which diseases were not notifiable or disease data were not available were excluded from rate calculations.

Interpreting Data

Incidence data in the Summary are presented by the date of report to CDC as determined by the MMWR week and
year assigned by the state or territorial health department. In addition, data in the
Summary are reported by the state in which
the patient resides at the time of diagnosis. For many of the nationally notifiable infectious diseases, surveillance data
are
independently reported to EPO and other CDC programs. Thus, surveillance data reported by other CDC programs may
vary from data reported in the Summary because of differences in 1) the date used to aggregate data (e.g., date of report, date of disease occurrence), 2) the timing of reports, 3) the source of the data, 4) surveillance case definitions, and 5) policies regarding case jurisdiction (i.e., which state should report the case to CDC).

The data reported in the Summary are useful for analyzing disease trends and determining relative disease burdens.
However, these data must be interpreted in light of reporting practices. Disease reporting is likely incomplete, and its completeness may vary depending on the disease. The degree of completeness of data reporting may be influenced by the diagnostic
facilities available; the control measures in effect; public awareness of a specific disease; and interests,
resources, and priorities of state and local officials responsible for disease control and public health surveillance. Finally, factors such as changes in methods for public health surveillance, introduction of new diagnostic tests, or discovery of new disease entities can cause changes in
disease reporting that are independent of the true incidence of disease.

Public health surveillance data are published for selected
racial and ethnic population groups because these variables can
be risk markers for certain notifiable diseases. Race and ethnicity data can also be used to highlight populations for focused prevention efforts. However, caution must be used when drawing conclusions from reported race and ethnicity data.
Different racial/ethnic population groups may have differential patterns of access to health care, potentially resulting in data that are not representative of true racial/ethnic group--specific disease incidence. Surveillance data reported to NNDSS are either
in individual case-specific form or summary form (aggregated data for a group of cases). Summary data often lack
demographic information (e.g., race); therefore, the demographic-specific incidence rates presented in the
Summary may be underestimated.

In addition, not all race and ethnicity data are collected
uniformly for all diseases. For example, some disease programs
collect race and ethnicity as one variable; other programs collect these data as two variables. Additionally,
although the recommended standard for classifying a person's race or ethnicity is based on self-reporting, this procedure might not always be followed.

Highlights for 2002

AIDS

Since 1981, confidential name-based AIDS surveillance has been the cornerstone of national, state, and local efforts
to monitor the scope and impact of the HIV epidemic. The data have many uses, including developing policy to help prevent
and control AIDS. However, because of the introduction of therapies that effectively slow the progression of the infection, AIDS data no longer adequately represent the populations
affected by the epidemic. By providing a window into the epidemic at
an earlier stage, HIV data, combined with AIDS data, better represent the overall impact. Since 1998, 30 areas (29 states and the U.S. Virgin Islands) have had integrated name-based HIV surveillance into their AIDS surveillance systems while
other jurisdictions have used other methods for reporting cases of HIV infection.

During1998--1999, declines in AIDS began to level, and essentially no change occurred during 1999--2002. This
trend follows a period of sharp declines in incident cases after 1996, when highly effective antiretroviral therapies were introduced. The estimated annual number of deaths among persons with AIDS, however, declined 14% from 1998 to 2002. At the end of 2002, an estimated 384,906 persons were known to be living with AIDS.

Anthrax

In November 2002, the Advisory Committee on Immunization Practices (ACIP) recommended preexposure use
of anthrax vaccine for groups at risk for repeated exposures,
including 1) laboratory personnel handling environmental
specimens and performing confirmatory testing for
Bacillus anthracis in U.S. Laboratory Response Network for Bioterrorism level
B laboratories or above, 2) workers making repeated entries into known
B. anthracis spore-contaminated areas after a
terrorist attack, and 3) workers in other settings in which repeated exposure to aerosolized
B. anthracis spores might occur. The ACIP recommendations are available at
http://www.cdc.gov/mmwr/PDF/wk/mm5145.pdf.

Brucellosis

By 2002, the control program for brucellosis among cattle in the United States had nearly eliminated
Brucella abortus infection from U.S. herds. Therefore, at present, the risk of contracting brucellosis either from occupational exposure to livestock in the United States or from domestically produced food items is minimal. However, a risk remains for infection
with both B. abortus and B.
melitensis from consumption of unpasteurized goat and cow milk products, in particular those
produced outside the United States. Most cases in the United States are now seen in international travelers or recent
immigrants. Laboratory personnel working with
Brucella species and hunters exposed to infected wildlife also have an
elevated risk for infection. B. melitensis and
B. suis are considered Category B bioterrorism threat agents.

Chancroid

During 2002, a total of 67 cases of chancroid were reported (rate: 0.02/100,000), an increase from 38 cases in 2001 but
an overall decline of 99% of the cases reported since 1987
(1). Of the 2002 cases, 43 (64%) were reported from one state.
Overall, only 10 states and one outlying area reported
>1 case of chancroid in 2002. The causative agent of chancroid is
difficult to culture and therefore the disease could be substantially underdiagnosed. Several studies that used DNA amplification
tests (which are not commercially available) have identified this infection in cities where it was previously
undetected (2).

Chlamydia trachomatis, Genital Infection

During 2002, a total of 834,555 cases of genital chlamydial infection were reported (rate: 296.55/100,000). This rate was
the highest since voluntary case reporting began in the mid-1980s and the highest since genital chlamydial
infection became a nationally notifiable disease in 1995
(1). This increase could be caused in part by the continued expansion of
chlamydia screening programs and increased use of more sensitive
diagnostic tests for this condition. From 1998 to 2002, the reported chlamydial infection rate in men increased
by 55% compared with a 20% increase in women. However, the
rate among women was over three times the rate reported among men, reflecting the larger number of women screened for
this disease.

Cholera

During 1995--2002, a total of 66 laboratory-confirmed cases of cholera, all caused by
Vibrio cholerae O1, were reported to CDC. Forty-two (64%) infections were acquired outside the United States, whereas six (9%) were acquired through consumption of contaminated seafood harvested in Gulf Coast waters. One patient died
(1). Only two laboratory-confirmed cases of cholera were reported to CDC in 2002. Both were caused by
V. cholerae O1 and were acquired outside the
United States. Both isolates were resistant to furazolidone. Production and sale of the only licensed cholera vaccine in the United
States ceased in 2001.

Coccidioidomycosis

In recent years, Arizona and California have experienced significant increases in the incidence rates of
coccidioidomycosis. This increase is likely related to demographic and climatic changes. Physicians should maintain a high suspicion for
acute coccidioidomycosis, especially among patients with a flu-like illness who live in or have visited areas with endemic disease.

Diphtheria

During 2002, one probable, nonfatal case of diphtheria was reported to CDC. The patient was a female resident
of California, aged 38 years. Symptoms and signs included a sore throat and difficulty in swallowing for 7 days, an
extensive pharyngeal membrane, and low-grade fever 99°--101°F. A throat swab specimen for culture was negative for
Corynebacterium diphtheriae, but it was obtained a day after an antibiotic regimen was started. The patient had recent, prolonged, frequent face-to-face exposure to visitors from eastern Europe and Australia. She had received the last booster dose of
vaccine in 1987.

Encephalitis, Arboviral

In 2002, an unprecedented epidemic and epizootic of West Nile virus (WNV) occurred in the United States
(1). Epidemic and epizootic activity was most intense in the central United States. A total of 2,146 human WNV encephalitis
and/or meningitis (i.e., meningoencephalitis) cases were reported through the ArboNet Arboviral Surveillance System from 36
states, representing the largest arboviral meningoencephalitis epidemic documented in the Western Hemisphere. In
addition, WNV-infected birds, mosquitoes, or horses were detected in 44 states and the District of Columbia. Of these 45 jurisdictions, 16 reported their first ever WNV activity. One human
case reported in a Los Angeles County, California, resident with no
known travel history and a report of a WNV-infected horse in Island County, Washington, indicated the complete
transcontinental movement of WNV within 3 years of its first appearance in the Eastern United States. An unprecedented equine WNV epizootic occurred in the midwestern states and resulted in 14,539 reported cases. Three mosquito species,
Culex pipiens, Cx. quinquefasciatus, and
Cx. restuans, accounted for the majority of the 6,604 reported WNV-positive mosquito pools. WNV was also detected for the first time in Cx. tarsalis, an important vector of St. Louis
encephalitis virus, raising concerns about its potential to transmit WNV to humans in western states where it is common (2).

In 2002, 164 cases of encephalitis caused by California (CAL) serogroup viruses were reported from 16 states, representing the most reported to CDC in any year since 1964. WNV human case surveillance may have resulted in improved surveillance for CAL serogroup virus meningoencephalitis cases. During 1964--2002, a median of 67 cases (average: 80; range: 29--167) were reported per year in the United States.

Gonorrhea

During 2002, a total of 351,852 cases of gonorrhea were reported (rate: 125.03/100,000 population). This rate is slightly lower than rates in 2001 (128.53/100,000), 2000 (129.04/100,000), 1999 (132.32/100,000), and 1998
(131.89/100,000) (1). In 2002, the reported gonorrhea rate among women (125.3/100,000) was similar to that among men (124.2/100,000). Rates among non-Hispanic black women aged 15--19 years (3,307.7/100,000) and non-Hispanic black men aged 20--24 years (3,256.2/100,000) remain higher than in any other racial/ethnic or age group. Increases have been observed in some
areas among men who have sex with men (2). Decreased susceptibility to the fluoroquinolone antibiotics has also been reported
from some regions (3). In 2002, the prevalence of fluoroquinolone-resistant
Neisseria gonorrhoeae infections continued to increase
in California. Fluoroquinolones are no longer advised for treatment of gonorrhea in Hawaii or California or for infections
that might have been acquired in those states
(4).

Haemophilus influenzae, Invasive Disease

In 2002, 331 cases of invasive Haemophilus
influenzae disease in children aged <5 years were reported; 34 (10%)
were reported as H. influenzae type b (Hib), 144 (44%) were reported as other serotypes or nontypeable isolates, and 153
(46%) were reported with serotype information unknown or missing. The continued remarkably low number of invasive
Hib infections in children (down from an estimated 20,000 cases annually in the prevaccine era) is a result of the successful
delivery of highly effective conjugate Hib vaccines to children, beginning at age 2 months
(1,2). Because discrepancies in serotyping results have occurred between laboratories, CDC requests that state health departments obtain and send all invasive H. influenzae isolates from children aged <5 years to CDC for serotype confirmation
(3,4).

Hantavirus Pulmonary Syndrome

The geographic center of hantavirus pulmonary syndrome (HPS) cases during the 2002 season was more northerly than
in previous years. This reflects weather patterns that delivered greater rainfall or milder antecedent winter conditions resulting in more abundant food supplies and an increase in the host rodent species in those northerly areas. CDC guidance for
prevention of HPS has been updated and made available in Spanish and English
(1).

Hepatitis A

Hepatitis A vaccine is recommended for persons at increased risk of acquiring hepatitis A (e.g., international travelers,
men who have sex with men (MSM), and injection- and noninjection-drug users)
(1) and also for children in states and
counties that have historically had consistently elevated rates of hepatitis A
(2). Since childhood vaccination in high-risk areas
was recommended, the overall hepatitis A rate has declined steadily, and in 2002, it was the lowest yet recorded (3.1/100,000). The decline in rates has been greater among children and in states where routine childhood vaccination is recommended,
suggesting an impact of childhood vaccination. The dramatic declines in disease rates in these groups and
areas that have historically accounted for the majority
of reported cases have resulted in a shift in the epidemiology of this disease in the United
States. Hepatitis A rates, historically much higher in the western states, are now similar in all
regions of the United States, and an increasing proportion of cases are among adults, particularly those in high-risk groups such as MSM. Continued monitoring of disease rates is needed to determine if the current low rates are sustained and attributable to vaccination and to identify
groups and areas where additional vaccination efforts are needed.

Hepatitis B

During 2002, a total of 7,996 acute hepatitis B cases were reported, representing a >65% decrease since 1990 (21,102
cases). The steady decline in hepatitis B rates coincides with the implementation of a national strategy to achieve the elimination
of hepatitis B virus (HBV) infection (1). The primary elements of this strategy are 1) screening of all pregnant women for HBV infection with provision of postexposure prophylaxis to infants born to infected women, 2) routine vaccination of all
infants and children aged <18 years, and
3) vaccination of others at increased risk of acquiring hepatitis
B (e.g., health-care workers, MSM, injection drug users, and household and sex contacts of persons with chronic HBV
infection).

The rate among children aged <18 years, the age group covered by the recommendation for routine
childhood immunization, has declined by approximately 90% since 1990. In comparison, high rates of disease continue among
adults, particularly males aged 25--39 years. This and the high proportion of cases occurring among persons in identified risk groups (i.e., injection-drug users, MSM and persons with multiple sex partners) indicate a need to strengthen efforts to reach these populations with vaccine.

Hepatitis C; Non-A, Non-B

Monitoring acute hepatitis C rates nationally has been challenging because 1) no serologic marker for acute infection
exists, and 2) many health departments do not have the resources to determine if a positive laboratory report for hepatitis C virus (HCV) infection represents acute infection. Consequently, the most reliable estimates of acute hepatitis C incidence
have historically come from sentinel surveillance. Incidence of hepatitis C has declined by >80% since the late 1980s, largely the result of a decrease in cases among injection-drug users, the reasons for which are unknown. The majority of hepatitis C cases continue to occur among persons aged >25 years, with injection-drug use the most common risk factor for infection.

In recent years, analysis of cases of acute, symptomatic hepatitis C reported through NNDSS has yielded similar results as those from sentinel surveillance, suggesting that the quality of national surveillance data for acute hepatitis C has improved. Direct reporting of anti-HCV--positive test results by laboratories has increased the completeness of reporting of HCV-infected persons to health departments. Reporting other available laboratory or clinical data would improve
surveillance for hepatitis C by providing information to identify patients with acute disease. Improving the accuracy of hepatitis C surveillance data continues to be a priority because monitoring hepatitis C incidence trends provides information needed to evaluate
the effectiveness of prevention efforts and identify opportunities for prevention.

HIV Infection, Adult

By December 2002, 49 states and the District of Columbia had an HIV surveillance system in place. Since 1998, 30 areas (29 states and the U.S. Virgin Islands) have had laws or regulations requiring confidential reporting by name for adults/adolescents or children with confirmed HIV infection, in
addition to reporting of persons with AIDS
(1). CDC also initiated a pilot system in 2002 to monitor HIV incidence. Beginning in 2003, CDC expanded its HIV/AIDS surveillance activities through the addition of a national HIV behavioral surveillance system. CDC will assess the implementation and
effectiveness of prevention activities through several monitoring systems, including the use of new performance indicators for state and local health departments and community-based organizations.

At the end of 2002, 142,713 adults and adolescents in the 30 areas were known to be living with HIV infection (not
AIDS). The prevalence rate of HIV infection (not AIDS) in this group was 125.7/100,000 population
(1).

HIV Infection, Pediatric

Effective January 1, 2000, the surveillance case definition for HIV infection was revised to reflect advances in laboratory
HIV virology tests. The definition incorporates the reporting criteria for HIV infection and AIDS into a single case definition
for adults and children (1).

In the 30 areas (29 states and the U.S. Virgin Islands) that have had laws or regulations since 1998 requiring
confidential reporting by name for children with confirmed HIV infection, 1,416 children (aged <13 years) were known to be living with HIV infection (not AIDS) at the end of 2002. The prevalence rate of HIV infection (not AIDS) in this group was
5.6/100,000 population (2).

Lyme Disease

A total of 23,763 cases of Lyme disease were reported in 2002, a 39% increase over 2001 and the highest
number reported since national surveillance began in 1982. As in previous years, the majority of cases were reported from
the northeastern and north-central United States. Factors potentially contributing to the overall increase in Lyme disease include better reporting, increased development in wooded areas, and growing deer populations. In addition, ecological studies suggest that infected ticks are spreading to new areas. The only Lyme disease vaccine licensed in the United States (LYMErix®) was removed from the market in February 2002. New
products aimed at reducing ticks on mice and deer are under development.

Malaria

Almost all malaria cases are imported, with more than twice as many cases occurring among U.S. residents traveling
to malarious areas as occur among foreign residents immigrating to or visiting the United States
(1). Over 75% of cases among U.S. residents occur in persons who were either not taking malaria chemoprophylaxis or did not take recommended drugs (1).The annual number of cases has increased during the past 15 years, likely because of increases in both international
travel (2) and immigration (3), as well as the spread and intensification of antimalarial drug resistance globally
(4).

Office of Travel and Tourism Industries. International travelers to and from the U.S.---international visitors (inbound) and U.S. residents (outbound), 1992-2002r. Washington, DC: US Department of Commerce, ITA, Office of Travel and Tourism Industries. Available at
http://www.tinet.ita.doc.gov/view/f-2001-05-001/index.html.

US Census Bureau. Current population reports. Series P23-206. Profile of the foreign-born population in the United States, 2000. Washington, DC: US Government Printing Office, 2001. Available at
http://www.census.gov/prod/2002pubs/p23-206.pdf.

Measles

A record low of 44 confirmed measles cases was reported in 2002, with cases occurring in 17 states. Eighteen cases
were internationally imported, and exposure to these cases resulted in 15 additional cases. Three other cases had only
virologic evidence of importation (i.e., genotypic analysis of measles viruses indicated an imported source). The remaining eight cases were classified as unknown source cases because no link to importation was detected. The majority of cases were either
in infants aged <12 months (18 cases) or persons aged >20 years (19 cases); only three cases occurred among children aged <5 years, and four cases among those aged 5--19 years. Three outbreaks, ranging in size from 3 to 13 cases, accounted for 43% of cases (n=19). In two of these outbreaks, the source cases were imported.

Pertussis

During 2002, 9,771 cases of pertussis were reported (rate: 3.4/100,000), the highest number of reported cases since 1964.
Of these cases, 21% occurred among infants aged <6 months (108.8/100,000), who were too young to have received the first 3 of the 5 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine recommended by age 6; 3%
occurred among children aged 6--11 months (15.4/100,000); 14% among children aged 1--4 years (8.9/100,000); 10% among
children aged 5--9 years (4.8/100,000); 29% among persons aged 10--19 years (7.0/100,000); and 23% among persons aged >20 years (1.2/100,000).

Since 1995, the coverage rate with >3 doses of pertussis vaccine has been >94% among U.S. children aged 19--35
months (1). Since 1980, the number of reported cases of pertussis in infants aged <6 months and in adolescents and adults has increased in some states (2). The reasons for this increase are unknown but could include increased awareness of pertussis among health-care providers, better reporting of cases to health departments
(3), and possibly an increase in
circulating Bordetella pertussis. The true number of pertussis cases in adolescents and adults has likely been underreported because the pertussis cough is not pathognomonic for pertussis, persons may not seek medical care for a cough illness, and (if medical
care is sought) diagnostic tests are not sufficiently sensitive. Adolescents and adults can become susceptible to disease when vaccine-induced immunity wanes, approximately 5--10 years after pertussis vaccination. The incidence of reported pertussis among children aged 7 months to 9 years has been relatively stable, suggesting protection against pertussis by
routine vaccination according to the recommended schedule.

Cherry JD. The science and fiction of the "resurgence" of pertussis. Pediatrics 2003;112:405--6.

Shigellosis

Shigella sonnei infections continue to account for over 75% of shigellosis in the United
States(1). Prolonged, multistate outbreaks of
S. sonnei infections that are transmitted in day care centers, where maintenance of good hygienic
conditions requires special care, account for much of the problem
(2). From June 2001 through March 2003, one such outbreak in
six eastern states accounted for over 3,000 laboratory-confirmed infections
(3). S. sonnei can also be transmitted
through contaminated foods and through water used for drinking or recreational purposes
(4). Recent evidence suggests that S.
sonnei infections may be increasing among men who have sex with men
(1).

During 2002, 986 cases of invasive group A streptococcal (GAS) disease were reported from nine states
(California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee) through the Active Bacterial
Core Surveillance (ABCs) project under CDC's Emerging Infections Program
(1). Based on these 986 cases, CDC estimates
that approximately 9,100 cases of invasive GAS disease (rate: 3.2/100,000) and 1,350 deaths occurred nationally during
2002. Disease incidence was highest among children aged <1 year (6.9/100,000) and adults aged >65 years
(8.9/100,000). Streptococcal toxic-shock syndrome and necrotizing fasciitis
accounted for approximately 5.9% and 6.1% of invasive
cases, respectively. The overall case-fatality rate among persons with invasive GAS disease was 14.6%.

In 2002, CDC published recommendations for the control of invasive group A streptococcal disease among household contacts of persons with invasive GAS infections and for
responding to postpartum and postsurgical infections.
These recommendations are based on routine surveillance data, studies of the epidemiology of subsequent invasive GAS
infections among household contacts of case-patients and postpartum and postsurgical GAS clusters, and studies of the effectiveness of chemoprophylactic regimens for eradicating carriage
(2--4).

The Prevention of Invasive Group A Streptococcal Infections Workshop Participants. Prevention of invasive group A streptococcal disease
among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the Centers for Disease Control and Prevention. Clin Infect Dis 2002;35:950--9.

Streptococcus pneumoniae, Invasive, Drug-Resistant

In 2002, the Active Bacterial Core Surveillance (ABCs) project of CDC's Emerging Infections Program
(1) collected information on invasive pneumococcal disease, including drug-resistant
Streptococcus pneumoniae, in nine states
(California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee). For the second straight year,
the proportion of pneumococcal isolates that were drug resistant declined. Of the 3,012
S. pneumoniae isolates collected in 2002, 9.1% exhibited intermediate resistance to penicillin (minimum inhibitory concentration [MIC] 0.1--1 µg/mL), and 11.5% were fully resistant (MIC >2 µg/mL)
(2). For cefotaxime, 8.4% of all isolates had intermediate resistance and 3.5% were
fully resistant in 2001. For erythromycin, 16.4% were resistant in 2001. Approximately one in eight (13.2%) isolates had
reduced susceptibility to at least three classes of drugs commonly used to treat pneumococcal
infections, a decline from a peak of one in five (18.3%)
isolates in 2000.

In February 2000, the Food and Drug Administration
licensed a pneumococcal conjugate vaccine for use in infants
and young children. In October 2000, the Advisory Committee on Immunization Practices issued recommendations for use of
the vaccine in children aged <5 years (3). Vaccine use has reduced rates of invasive pneumococcal disease markedly among
children, the vaccine's target age group, but also among unvaccinated older persons
(4).

Syphilis, Congenital

During 2002, a total of 412 cases of congenital syphilis were reported (10.20/100,000 live births), down from 492 in
2001. Like primary and secondary syphilis, the rate of congenital syphilis has declined sharply in recent years, from a peak of
107.3/
100,000 in 1991 (1). The continuing decrease in the rate of congenital syphilis likely reflects the substantial reduction in
the rate of primary and secondary syphilis among women that has occurred in the last decade and continues to occur.
Congenital syphilis persists in the United States because a substantial number of women do not receive syphilis serologic testing until
late in their pregnancy or not at all. This lack of screening is often related to absent or late prenatal care
(2).

Syphilis, Primary and Secondary

During 2002, a total of 6,862 primary and secondary syphilis cases were reported, an increase from 6,103 cases in
2001. From 1990 to 2000, the primary and secondary syphilis rate declined 90%, from 20.34/100,000 to 2.12/100,000. The
2001 rate (2.2/100,000), the first annual increase in syphilis in over a decade, was 2.1% higher than the 2000 rate, which was the lowest since reporting began in 1941. The 2002 rate (2.4/100,000) was 9.1% higher than the reported rate in 2001. The
2002 primary and secondary syphilis rate reflects a 27% increase among men from 2001 but a 21% decrease among women
(1). This disparity between men and women, observed across all racial and ethnic groups, along with reported outbreaks of syphilis among MSM in large urban areas, suggests that increases in syphilis are occurring among MSM. Rates
remain disproportionately high in the South and among non-Hispanic blacks, but rates in these two groups are continuing to decline (1,2,3).

Tetanus

In 2002, 25 cases of tetanus were reported from 14 states. Three (12%) cases were among persons aged <25 years, 12
(48%) cases were among persons aged 25--59 years, and 10 (40%) cases were among persons aged >60 years. Although the annual number of reported cases continues to decrease, the percentage of cases among persons aged 25--59 years has increased during the last decade; previously, most cases were among persons aged >60 years
(1). Three (12%) of the cases were fatal.

Tuberculosis

During 2002, a total of 15,075 cases (rate: 5.3/100,000) of tuberculosis (TB) were reported to CDC from the 50 states
and the District of Columbia, representing a 5.7% decrease from 2001 and a 43.5% decrease from 1992, when the number
and rate of cases most recently peaked in the United States
(1).

Despite a 68.4% decline in case rates from 1992 to 2002 (31.0/100,000 to 9.8/100,000), U.S.-born non-Hispanic
blacks continued to have the highest TB rate of any U.S.-born racial/ethnic population
(2). U.S.-born, non-Hispanic blacks had the largest number of TB cases among both U.S.-born and foreign-born populations, representing 46.7% of TB cases among U.S.-born persons and approximately one fourth of all cases (2).

In 1992, 72.6% of reported cases were among U.S.-born persons (8.2/100,000), and 27.4% were among
foreign-born persons (34.5/100,000). In comparison in 2002, 48.2% of reported cases were among U.S.-born persons (2.8/100,000),
and 51.8% of reported cases were among foreign-born persons (23.6/100,000)
(2).

Despite the decrease in case rate among foreign-born persons during the past decade, more than half the TB cases in
the United States in 2002 occurred in this population, and the case rate was eight times greater in this population than
among U.S.-born persons. To address the high rate, CDC is collaborating with public health partners to implement TB
control initiatives among recent international arrivals and residents along the border between the United States and Mexico and
to strengthen TB programs in countries with a high incidence of TB disease
(2). CDC recently updated its comprehensive national action plan to reflect the alignment of its priorities with the Institute of Medicine report (3) and to ensure that priority
prevention activities are undertaken with optimal collaboration and coordination among national and international
public health partners (4).

CDC. Reported tuberculosis in the United States, 2002. Atlanta, GA: US Department of Health and Human Services, CDC, 2003.
Available at
http://www.cdc.gov/tb.

Institute of Medicine. Ending neglect: the elimination of tuberculosis in the United States. Washington, DC: National Academy Press, 2000.

CDC. CDC's response to ending neglect: the elimination of tuberculosis in the United States. Atlanta: US Department of Health and Human
Services, CDC, 2002.

Typhoid Fever

In 2002, typhoid fever was diagnosed in 321 persons in the United States (NNDSS data), despite the availability of
two effective vaccines. Approximately 80% of these cases occurred among persons who reported international travel during the preceding 6 weeks. Persons visiting friends and relatives in their country of origin appear to be at higher risk (1). In many areas of the world,
Salmonella Typhi strains have acquired resistance to multiple antimicrobial agents, including
ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole
(1). S. Typhi outbreaks in the United States are usually small in size
but can cause significant morbidity and are often foodborne, warranting thorough investigation (2). Recently a sexually transmitted outbreak of typhoid fever was recognized and reported (3).

Varicella deaths

In 2002, nine varicella deaths were reported to CDC from eight states
(1). Three of the deaths occurred among children
aged 5--11 years, and six occurred among adults aged 26--74 years. In 1999, the Council of State and Territorial
Epidemiologists recommended that varicella deaths be reported to CDC to monitor the impact of routine varicella vaccination on varicella-related mortality (2). However, reporting of varicella deaths is incomplete, limiting the usefulness of mortality data in assessing the impact of the varicella vaccination program. CDC encourages states to report varicella deaths so that risk factors
for varicella-related mortality can be identified and the percentage of deaths that would have been directly preventable by
following current recommendations for vaccination can be determined.

In 2003, as an adjunct to mortality surveillance, varicella infection was again designated a nationally notifiable
condition. The objectives of varicella morbidity surveillance at state and national levels are to monitor the epidemiology of varicella by
age, place, and over time, to monitor the impact of widespread and increasing immunization on the epidemiology of varicella,
and to allow prompt implementation of disease control measures
(3).

Council of State and Territorial Epidemiologists. CSTE position statement 1998-ID-10: inclusion of varicella-related deaths in the National
Public Health Surveillance System (NPHSS). Available at
http://www.cste.org/ps/1998/1998-id-10.htm.

American Society of Heating, Refrigerating, and
Air-Conditioning Engineers. ASHRAE Guideline 12-2000. Minimizing
the risk of legionellosis associated with building water systems. Atlanta: American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc., 2000:1--17. Available at
http://www.baltimoreaircoil.com.

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Department of Health and Human Services. CDC is not responsible for the content
of pages found at these sites. URL addresses listed in MMWR were current as of
the date of publication.

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